Provider Demographics
NPI:1457836744
Name:JASEN, LAURA MARIE
Entity Type:Individual
Prefix:MS
First Name:LAURA
Middle Name:MARIE
Last Name:JASEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4532 W KENNEDY BLVD # 166
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33609-2042
Mailing Address - Country:US
Mailing Address - Phone:813-539-8990
Mailing Address - Fax:
Practice Address - Street 1:3825 HENDERSON BLVD STE 405
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33629-5012
Practice Address - Country:US
Practice Address - Phone:813-539-8990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-02
Last Update Date:2018-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH16331101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health